Early Pregnancy

Question 1

What is the action of hCG?

Answer 1

Stimulates corpus luteum to produce progesterone, which is necessary to maintain pregnancy until 8 weeks. At this point, the placenta takes over production of hCG

Question 2

How early can hCG be detected?

Answer 2

Several days before the scheduled period

Question 3

What is a biochemical pregnancy?

Answer 3

Failure of implantation. There is an initial positive hCG that then becomes negative.

Question 4

How soon can pregnancy be detected on USS? What is the order + timings of when things appear?

Answer 4

At 5 weeks (after LMP), the gestational sac can be seen within the uterus. The circular yolk sac is then visible, followed by the embryo at 5.5 weeks.

Question 5

Define a miscarriage

Answer 5

Pregnancy that ends spontaneously before 24 weeks

Question 6

Name the types of miscarriage and describe (bleeding, os, FH, etc)

Answer 6

Threatened: bleeding, os closed, FH present
Inevitable: bleeding, os open, no FH
Incomplete: bleeding, os open, RPOC visible
Complete: no bleeding, os closed, empty uterus
Missed: no bleeding, os closed, no FH

Question 7

A 25 year old G1P0 is seen in EPAU with PV bleeding and mild abdominal crampy pain. She is 9 weeks pregnant. The external os is open. On TVUSS, there is a visible fetus with CRL 24mm with no heartbeat. What is the likely diagnosis?

Answer 7

This woman has had a miscarriage. Bleeding, os open, no FH. Because the CRL is >7mm without a fetal heartbeat, you can confidently say this is a miscarriage.

Question 8

How common are miscarriages?

Answer 8

Very common. About 10-20% of pregnancies end in miscarriage.

Question 9

A pregnant woman 10/40 presents with PV bleeding. What are 3-4 differential diagnoses, and what would you want to know from history/examination/Ix to rule these in or out?

Answer 9

Miscarriage: pain, state of the os, TVUSS for FH
Ectropion: PCB, examine cervix
Infection: discharge, pain during sex, swabs
Cervical cancers: last smear, examine cervix

Question 10

Name some causes of miscarriage.

Answer 10

Chromosomal abnormalities
Illness
Uterine abnormality
Infections
Drugs/chemicals

Question 11

A 30 year old pregnant woman comes to A&E with PV bleeding. She is 9 weeks pregnant. The bleeding started a few hours ago, and is quite heavy. She has had to use 2 pads and it is still ongoing. Describe your management of this case.

Answer 11

If unstable, A-E approach 
Take a full history 
Abdo and pelvic exam
TVUSS 
Consider further management as needed

Question 12

Describe the management of miscarriage and the indications.

Answer 12

3 different types:

• Expectant: wait 7-14 days for bleeding to resolve. Usually if early loss, inevitable + incomplete.
• Medical: misoprostol 800ug intravaginal. For missed + incomplete as alternative to or next step after expectant management.
• Surgical: manual vacuum aspiration with misoprostol to ripen cervix. If larger fetus (greater risk of heavy bleeding with medical Mx), failure of medical management, excessive bleeding, unstable, infected RPOC, woman’s preference.

Question 13

A 30 year old woman attends A&E with PV bleeding. She is 7 weeks pregnant. On examination she is stable, the external os is open. On TVUSS, a fetus is seen with CRL of 6.5mm and there is no FH. What management would you advise?

Answer 13

This is likely to be a miscarriage. As the CRL is <7mm, the most appropriate management would be expectant until a repeat USS in 7 days confirms the diagnosis. If she is still bleeding at that time and a miscarriage is diagnosed, she would then have a choice between expectant, medical or surgical management, unless there were any contraindications to any of the above options. Whichever she chooses, she will need to do a hCG test at 3 weeks to check that the miscarriage is complete.

Question 14

A 28 year old woman comes to A&E with continuous PV bleeding. She was diagnosed with a miscarriage 2 weeks ago and had opted for expectant management at the time. What would you do now?

Answer 14

• A-E if unstable
• History, can ask for symptoms of infection
• Abdo exam (checking for tenderness)
• Urine pregnancy test
• Bloods
• Refer to EPAU

Question 15

In which cases are you required to rescan in 7-14 days to diagnose miscarriage?

Answer 15

1. If the mean sac diameter is <25mm (with or without yolk sac). 14 days
2. If the mean sac diameter is 25+mm with a yolk sac but no fetal pole. 7 days.
3. If the CRL <7mm (and no FH). 7 days.

Question 16

What would you need to tell a woman who has opted for expectant management of miscarriage?

Answer 16

• Explain what it is and most women will need no further treatment
• Explain risks of infection, pain, bleeding (no greater than other types of management)
• Provide written info
• Safety net
• If bleeding stops within 2 weeks, take a hCG test after 3 weeks and come back if still positive
• If bleeding continues or increases at 2 weeks, come back for another check up

Question 17

What would you tell a patient who is having medical management of miscarriage?

Answer 17

• Explain what it involves
• Explain side effects of pain, n+v, bleeding. Offer pain relief and antiemetics
• Should contact healthcare professional if no bleeding in 24 hours (missed)
• Take a pregnancy test after 3 weeks and return if positive
• Provide written info
• Safety net (infection, severe pain or very heavy bleeding)

Question 18

What would you tell a woman who is having a surgical management of miscarriage?

Answer 18

• Explain what is involved and all of the options
• Explain complications: pain, bleeding, rarely infection (the same with any option), damage eg perforation (uncommon), cervical incompetence (rare), and risk of scarring of the endometrium (uncommon)
• Need to give anti-D if RhD negative
• Prophylactic antibiotics

Question 19

Define recurrent miscarriage

Answer 19

Recurrent miscarriage is defined as 3+ consecutive pregnancy losses

Question 20

What are some causes of recurrent miscarriage?

Answer 20

Infection, APS, older age, chromosomal abnormalities, uterine structural anomalies, obesity

Question 21

What are some investigations for recurrent miscarriage?

Answer 21

APS antibodies, imaging of the uterus, cytogenetic analysis and karyotyping

Question 22

A 25 year old comes in with PV bleeding at 8 weeks. Os closed, FH present. She wants to know how likely she is to have a miscarriage and if there’s anything she can do to prevent it. What would say?

Answer 22

25% will miscarry.

Bed rest, etc is not proven to reduce the risk.

Question 23

A 24 year old comes to A&E 7 days after attending EPAU where she was told she was likely having a miscarriage and to return in 7 days for a repeat scan. She has ongoing bleeding, and has had a fever and offensive discharge for the past 2 days. What is the likely diagnosis and what is your management?

Answer 23

This woman may have infected RPOC or endometritis. She should be given antibiotics after swabs for MC&S and have surgical removal of RPOC.

Question 24

Define ectopic pregnancy

Answer 24

Extrauterine pregnancy

Question 25

Name some risk factors for ectopic pregnancy

Answer 25

PID (hydrosalpinx, TOA), IUD, older age, IVF, previous ectopic or tubal surgery, smoking

Question 26

Describe the presentation of ectopic pregnancy

Answer 26

• May be incidental finding
• Pain, bleeding
• Rupture: sudden onset severe pain, bleeding, peritonism, low BP, tachycardia, etc

Question 27

A 23 year old woman presents to A&E with severe abdominal pain. She denies any PV bleeding. She has not had a period in 6 weeks. What are several differential diagnoses and how would you approach this case?

Answer 27

DDx: ectopic pregnancy, threatened miscarriage, PID, UTI, appendicitis
-A-E
-Full history
-Abdo and pelvic exam, obs, urine dip
-Bloods (FBC, U+Es, CRP, consider G&S, serum hCG)
Refer to EPAU If positive hCG

Question 28

If intrauterine pregnancy is in doubt, what tests can help to confirm?

Answer 28

TVUSS is best but does not always show IUP early on
Repeated serum hCG levels can also be useful. An increase by >66% in 48 hours is very likely to be IUP, while a plateau or decrease is not likely to be IUP.

Question 29

Describe the management of ectopic pregnancy?

Answer 29

Admit if symptomatic
Take bloods including FBC, G&S
Anti D if RhD neg
Decide if for expectant, medical or surgical management.

Question 30

Describe the management options of ectopic pregnancy and the indications.

Answer 30

Expectant: wait and monitor hCG measurement with follow up scan as the pregnancy may pass or be reabsorbed. Only if asymptomatic and stable, hCG <1000 and pregnancy <35mm.
Medical: IM methotrexate and monitor hCG every few days. If minimal symptoms, hCG <3000, pregnancy <35mm.
Surgical: Laparoscopy is best surgical approach, w/ salpingostomy or salpingectomy depending on presence/health of the other tube. If unstable, ruptured, severely symptomatic, or high hCG/large pregnancy. Give anti-D!

Question 31

Describe what you would tell a patient having a medical management of ectopic pregnancy

Answer 31

• Explain what is involved: injection plus monitoring levels of the pregnancy hormone in your blood every few days
• Side effects: abdo pain, N+V, sore eyes, photosensitivity
• Avoid sex during treatment until resolved and don’t get pregnant for 3 months after (methotrexate is dangerous to fetus), no alcohol, avoid sun

Question 32

Define hyperemesis gravidarum.

Answer 32

Pregnancy related nausea and vomiting so severe as to cause weight loss, electrolyte disturbance, or severe dehydration.

Question 33

How is hyperemesis gravidarum managed?

Answer 33

Admit if clinically indicated (severe dehydration, unable to retain fluids or food, electrolyte imbalance).
Rule out other causes of vomiting (DKA, UTI, gastroenteritis, molar pregnancy)
Rehydration
Anti-emetics: metoclopromide, ondansetron, cyclising
Thiamine replacement

Question 34

Define gestational trophoblastic disease

Answer 34

A group of conditions caused by abnormal placental trophoblast proliferation. Includes molar pregnancy, invasive mole, choriocarcinoma, etc.

Question 35

What is a complete mole? Partial mole?

Answer 35

Both are types of abnormally fertilised eggs
Complete mole: no maternal chromosomes. Fertilised by 1 or 2 sperm. 46XX, XY, YY
Partial mole: two sperm fertilise (dispermy) or one sperm fertilises then duplicates. 69XXX/XYY

Question 36

Describe the presentation of molar pregnancy

Answer 36

High levels of hCG with severe NVP
Vaginal bleeding
Pre eclampsia
On TVUSS: bunch of grapes/snowstorm appearance.

Question 37

A ew year old woman is seen in the EPAU with severe nausea and vomiting. A TVUSS shows a snowstorm appearance. What is the management of this condition?

Answer 37

Should be managed at a regional centre.
ERCP to remove the mole

Serial hCG levels to confirm resolution.

Question 38

What are the complications of molar pregnancy?

Answer 38

Persistent vaginal bleeding + hyperemesis.
Transformation to invasive mole or choriocarcinoma requiring chemotherapy
Recurrence in future pregnancies with need for more frequent monitoring.

Question 39

What is the appearance of an ectopic pregnancy on TVUSS?

Answer 39

Adnexal mass that moves separately to the ovary- ‘sliding sign’

Question 40

What are 2 signs on ultrasound of an early intrauterine pregnancy that can help differentiate between IUP and pseudo sac

Answer 40

Intradecidual and double decidual signs

Question 41

A 28 year old woman comes to A&E with continuous PV bleeding. She was diagnosed with a miscarriage 2 weeks ago and had opted for expectant management at the time. You decide to refer her to EPAU after initial management. On TVUSS, there is RPOC within the uterine cavity. She is stable, afebrile, abdo SNT, and urine pregnant test is positive. What would you advise this woman?

Answer 41

This woman has RPOC. Since she is stable and there are no signs of infection, she can either continue with expectant management as there is a chance she will pass the tissue naturally, or she can opt for medical or surgical management. These options should be explained to her and she should receive written info as well.